Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 81: Which of the following is NOT a mechanism of action of intrauterine contraceptive devices (IUCDs)?

A. Increased uterine motility
B. Aseptic inflammation
C. Altered cervical mucus
D. Inhibition of ovulation (Correct Answer)

Explanation: ### Explanation The primary mechanism of action for all Intrauterine Contraceptive Devices (IUCDs) is to create a **spermicidal intrauterine environment**. They do not interfere with the Hypothalamic-Pituitary-Ovarian (HPO) axis; therefore, **inhibition of ovulation is NOT a mechanism of IUCDs.** #### Why the other options are mechanisms of IUCDs: * **Aseptic Inflammation (Option B):** The presence of a foreign body (the IUCD) triggers a sterile inflammatory response in the endometrium. This leads to an increase in macrophages, lymphocytes, and plasma cells, which are toxic to spermatozoa and prevent implantation. * **Increased Uterine Motility (Option A):** The mechanical presence of the device increases uterine and tubal peristalsis, which alters the transport time of the ovum and sperm, preventing fertilization. * **Altered Cervical Mucus (Option C):** This is specifically characteristic of **Hormonal IUCDs (e.g., LNG-IUD/Mirena)**. The progestogen thickens the cervical mucus, making it "hostile" and impenetrable to sperm. #### High-Yield Clinical Pearls for NEET-PG: * **Copper T (Cu-T):** Primarily acts as a spermicide by releasing copper ions that inhibit sperm motility and viability. * **LNG-IUD (Mirena):** Its most important mechanism is thickening cervical mucus and causing endometrial atrophy. * **Ideal Candidate:** Multiparous women in a stable monogamous relationship. * **Most Common Side Effect:** Bleeding (menorrhagia) is the most common reason for removal of Cu-T, whereas pain is the second most common. * **Post-Coital Contraception:** Cu-T 380A is the most effective emergency contraceptive if inserted within 5 days (120 hours) of unprotected intercourse.

Question 82: What is Grafenberg's ring?

A. A vaginal pessary to prevent uterine prolapse
B. A first-generation intrauterine device (IUD) (Correct Answer)
C. A mechanical barrier to prevent pregnancy
D. None of the above

Explanation: **Explanation:** **Grafenberg’s Ring** is a classic example of a **first-generation intrauterine device (IUD)**. Developed by Ernst Gräfenberg in the late 1920s, it was a circular coil made of silver (and later copper) alloys. 1. **Why Option B is correct:** First-generation IUDs are defined as **non-medicated (inert)** devices. They work primarily by inducing a sterile inflammatory response in the endometrium, which prevents implantation. While modern IUDs are medicated with copper or hormones, the Grafenberg ring was one of the earliest successful inert metallic devices used in clinical practice. 2. **Why other options are incorrect:** * **Option A:** A vaginal pessary (like a Ring or Hodge pessary) is a device inserted into the vagina to provide structural support for pelvic organ prolapse; it is not an intrauterine contraceptive. * **Option C:** Mechanical barriers refer to devices like condoms, diaphragms, or cervical caps that physically prevent sperm from entering the cervix. The Grafenberg ring is placed inside the uterine cavity, not as a barrier. **High-Yield Clinical Pearls for NEET-PG:** * **Generations of IUDs:** * **1st Gen:** Non-medicated/Inert (e.g., Lippes Loop, Grafenberg’s Ring). * **2nd Gen:** Medicated with Copper (e.g., Cu-T 380A, Multiload). * **3rd Gen:** Hormone-releasing (e.g., LNG-IUS/Mirena). * **Lippes Loop:** The most commonly used first-generation IUD; it is double-S shaped and made of polyethylene. * **Mechanism of Action:** The primary MOA of inert IUDs is a **foreign body reaction** causing biochemical changes in the uterine fluid that are toxic to sperm and blastocysts.

Question 83: Mala-N contains which of the following?

A. Ethinyl estradiol 30 mcg (Correct Answer)
B. Norgestrel 50 mcg
C. Ethinyl estradiol 50 mcg
D. Progesterone 10 mg

Explanation: **Explanation:** **Mala-N** is a combined oral contraceptive pill (COCP) provided free of cost under the National Family Welfare Programme in India. Understanding its composition is high-yield for NEET-PG. **1. Why Option A is Correct:** Mala-N (and its commercial counterpart Mala-D) consists of a fixed-dose combination of an estrogen and a progestin. The exact composition is: * **Estrogen:** Ethinyl Estradiol (EE) **30 mcg** (0.03 mg) * **Progestin:** Levonorgestrel (LNG) **150 mcg** (0.15 mg) Therefore, Ethinyl estradiol 30 mcg is the correct constituent. **2. Why Other Options are Incorrect:** * **Option B (Norgestrel 50 mcg):** Mala-N uses *Levonorgestrel* (the active isomer), not Norgestrel. Furthermore, the dose of progestin in Mala-N is 150 mcg, not 50 mcg. * **Option C (Ethinyl estradiol 50 mcg):** This represents a "high-dose" pill. Modern COCPs are "low-dose" (containing <50 mcg of EE) to minimize side effects like thromboembolism and nausea. * **Option D (Progesterone 10 mg):** This is not a constituent of standard COCPs. Progesterone is used in different dosages for HRT or withdrawal bleeding, but not in Mala-N. **3. Clinical Pearls for NEET-PG:** * **Mala-N vs. Mala-D:** Both have the same composition. The only difference is that **Mala-N is free** (N for "Nishulk"), while Mala-D is subsidized/paid (D for "Dhan"). * **Packaging:** One pack contains **28 tablets**: 21 white hormonal tablets and 7 brown non-hormonal tablets (containing **60 mg Ferrous Fumarate**) to maintain the habit of pill-taking and prevent anemia. * **Centchroman (Saheli):** Do not confuse Mala-N with Saheli. Saheli is a non-steroidal, once-a-week pill containing Ormeloxifene (30 mg). * **Mechanism:** Primarily acts by inhibiting ovulation via suppression of FSH and LH.

Question 84: In which year did family planning become voluntary in India?

A. 1977 (Correct Answer)
B. 1953
C. 1992
D. 1997

Explanation: **Explanation:** **Correct Option: A (1977)** The year 1977 marks a significant turning point in India’s demographic policy. Following the period of the Emergency (1975–1977), which was marred by reports of coercive and forced sterilizations, the newly formed government rebranded the "National Family Planning Programme" as the **"National Family Welfare Programme."** This shift was not merely nomenclature; it transitioned the policy from a target-oriented, coercive approach to a **completely voluntary** one, focusing on the "welfare" of the family rather than just population control. **Analysis of Incorrect Options:** * **B. 1953:** This is incorrect. India was the first country in the world to launch a National Family Planning Programme in **1952**. 1953 was the first full year of its implementation under the clinical approach. * **C. 1992:** This year is significant for the launch of the **Child Survival and Safe Motherhood (CSSM)** program, which integrated family planning with maternal and child health, but it was not the year the program became voluntary. * **D. 1997:** This year saw the launch of the **Reproductive and Child Health (RCH) Phase I**, which adopted the "Target Free Approach" (introduced in 1996), moving away from rigid contraceptive targets to a decentralized, demand-driven approach. **High-Yield Clinical Pearls for NEET-PG:** * **First Country:** India was the first to start a national program (1952). * **Red Triangle:** The symbol of the Family Welfare Programme in India. * **Current Strategy:** India currently follows the **"Mission Parivar Vikas"** (launched 2016) focusing on 145 high-fertility districts. * **Incentives:** Under the current voluntary scheme, the government provides compensation for loss of wages to acceptors of sterilization (Statutory requirement: Informed Consent).

Question 85: In the calendar method of contraception, what is the first fertile day of the menstrual cycle?

A. 10th day of the shortest menstrual cycle (Correct Answer)
B. 18th day of the shortest menstrual cycle
C. 10th day of the longest menstrual cycle
D. 18th day of the longest menstrual cycle

Explanation: ### Explanation The **Calendar Method (Ogino-Knaus Method)** is a natural family planning technique used to predict the fertile window based on the history of previous menstrual cycles. To calculate the fertile period, a woman must track her cycle length for at least 6 to 12 months. **1. Why Option A is Correct:** The fertile window is calculated by identifying the earliest and latest possible days of ovulation. * **First Fertile Day:** Calculated by subtracting **18 days** from the **shortest cycle**. * **Last Fertile Day:** Calculated by subtracting **11 days** from the **longest cycle**. In a standard 28-day cycle, the first fertile day would be Day 10 ($28 - 18 = 10$). Therefore, the **10th day of the shortest cycle** represents the beginning of the period where conception is most likely. **2. Why Incorrect Options are Wrong:** * **Option B:** Subtracting 18 days from the shortest cycle gives the *start* of the fertile period, not the 18th day itself. * **Option C & D:** The longest cycle is used to determine the **end** of the fertile period (by subtracting 11 days). Using the longest cycle to find the *first* fertile day would dangerously underestimate the fertile window, leading to a high failure rate. **3. Clinical Pearls for NEET-PG:** * **Standard Days Method:** A simplified version of the calendar method suitable for women with cycles between 26–32 days; the fertile window is fixed at **Days 8 to 19**. * **Pearl Index:** The failure rate of the calendar method is relatively high (approx. 9% with perfect use, up to 25% with typical use). * **Prerequisite:** This method is unreliable in women with highly irregular cycles, post-menarche, or in the perimenopausal period. * **Sperm Viability:** The subtraction of 18 days accounts for the 72-hour lifespan of sperm and the timing of ovulation.

Question 86: Which IUCD has the longest lifespan?

A. Progestasert
B. Cu T 380A (Correct Answer)
C. Mirena
D. Nova T

Explanation: **Explanation:** The lifespan of an Intrauterine Contraceptive Device (IUCD) is primarily determined by the amount of active medication or surface area of copper it contains. **Why Cu T 380A is the correct answer:** The **Cu T 380A** is a second-generation copper-bearing IUCD. The "380" signifies that it has a surface area of 380 mm² of copper wire. Due to this high copper content, it has the longest approved clinical lifespan among all commonly used IUCDs. According to WHO and the Government of India guidelines, it is effective for **10 years**. **Analysis of Incorrect Options:** * **Progestasert:** This was the first-generation hormone-releasing IUCD. It contained Progesterone and had a very short lifespan of only **1 year**, requiring annual replacement. * **Mirena (LNG-20):** This is a Levonorgestrel-releasing system. While highly effective, its approved lifespan is currently **5 to 8 years** (depending on the guideline), which is shorter than the Cu T 380A. * **Nova T:** This is a copper device with a silver core to prevent fragmentation. It contains 200 mm² of copper and has a lifespan of **5 years**. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Copper IUCDs act primarily as a **spermicide** by causing a local sterile inflammatory response in the endometrium. * **Ideal Candidate:** The Cu T 380A is the "Gold Standard" for long-term reversible contraception in parous women. * **Emergency Contraception:** Cu T 380A is the **most effective** method of emergency contraception if inserted within 5 days of unprotected intercourse. * **Cu T 375 (Multiload):** Has a lifespan of **5 years**.

Question 87: When is the Copper T IUD ideally inserted?

A. Just before menstruation
B. During menstruation (Correct Answer)
C. Just after menstruation
D. On the 14th day of the cycle

Explanation: **Explanation:** The ideal time for the insertion of a Copper T Intrauterine Device (IUD) is **during menstruation** (specifically within the first 7 days of the cycle). This timing is preferred for three primary clinical reasons: 1. **Exclusion of Pregnancy:** It provides the highest certainty that the woman is not pregnant, preventing accidental insertion during an early gestation. 2. **Ease of Insertion:** The cervical os is naturally slightly dilated during menses, making the procedure technically easier and less painful. 3. **Reduced Side Effects:** Post-insertion bleeding or spotting is masked by the menstrual flow, leading to better patient compliance. **Analysis of Incorrect Options:** * **A. Just before menstruation:** This is the least ideal time. The risk of inserting the IUD into an early (luteal phase) pregnancy is high. Furthermore, the cervix is firm and closed, increasing the risk of pain and uterine perforation. * **C. Just after menstruation:** While acceptable if pregnancy is strictly ruled out, the cervical os begins to close, making insertion slightly more difficult than during active menses. * **D. On the 14th day of the cycle:** This coincides with ovulation. Insertion at this stage carries a risk of "luteal phase pregnancy" where fertilization may have already occurred. **High-Yield Clinical Pearls for NEET-PG:** * **Post-Partum Insertion:** Can be done within 48 hours (PPIUCD) or after 6 weeks (involution complete). * **Post-Abortal:** Can be inserted immediately after a first-trimester abortion. * **Emergency Contraception:** Copper T is the most effective emergency contraceptive if inserted within **5 days** of unprotected intercourse. * **Mechanism:** Primarily **spermicidal**; it causes a sterile inflammatory response in the endometrium and alters cervical mucus.

Question 88: Absolute contraindications of oral contraceptive pills (OCPs) include all of the following EXCEPT:

A. Ischemic heart disease
B. Hepatoma
C. Thyroid disorder (Correct Answer)
D. Breast cancer

Explanation: Combined Oral Contraceptive Pills (OCPs) contain estrogen and progestogen. Estrogen, in particular, has significant metabolic, pro-thrombotic, and hepatic effects, leading to specific absolute contraindications where the risk of use outweighs any possible benefit (WHO Medical Eligibility Criteria Category 4). ### **Why "Thyroid Disorder" is the Correct Answer** Thyroid disorders (hypothyroidism or hyperthyroidism) are **not** contraindications for OCP use. While estrogen can increase thyroid-binding globulin (TBG) levels, it does not affect the free (active) hormone levels or the clinical management of thyroid disease. Patients with thyroid disorders can safely use OCPs. ### **Explanation of Incorrect Options (Absolute Contraindications)** * **Ischemic Heart Disease (IHD):** Estrogen increases the risk of thromboembolism and myocardial infarction. In patients with pre-existing IHD or multiple cardiovascular risk factors (e.g., smoking >35 years, hypertension), OCPs are strictly contraindicated. * **Hepatoma:** OCPs are metabolized in the liver and can stimulate the growth of hepatic adenomas or worsen liver function in the presence of malignant tumors (Hepatoma). Active viral hepatitis and cirrhosis are also contraindications. * **Breast Cancer:** Most breast cancers are hormone-sensitive. Estrogen can promote the proliferation of malignant cells; therefore, a current or past history of breast cancer is an absolute contraindication. ### **High-Yield Clinical Pearls for NEET-PG** * **Mnemonic for Absolute Contraindications (C-H-E-C-K):** **C**arcinoma (Breast/Endometrium), **H**istory of Thromboembolism/Stroke, **E**strogen-dependent tumors, **C**onfirmed pregnancy, **K**olestatic (Cholestatic) jaundice/Liver disease. * **Smoking:** OCPs are contraindicated in women >35 years who smoke >15 cigarettes/day. * **Migraine:** OCPs are contraindicated in women with **migraine with aura** due to the significantly increased risk of ischemic stroke.

Question 89: Which of the following is commonly used as a spermicide in contraceptives today?

A. Norethinosterol
B. Nonoxynol (Correct Answer)
C. DMPA
D. NET-EN

Explanation: **Explanation:** The correct answer is **Nonoxynol-9**, which is the most widely used spermicide globally. **1. Why Nonoxynol is Correct:** Nonoxynol-9 is a **non-ionic surfactant** (detergent). Its primary mechanism of action involves disrupting the lipid membrane of the spermatozoa's midpiece and tail. This leads to the loss of motility and eventual destruction of the sperm cell membrane, preventing it from reaching and fertilizing the ovum. It is commonly found in contraceptive foams, jellies, creams, and as a coating on some condoms and diaphragms. **2. Why the Other Options are Incorrect:** * **Norethinosterol (Norethisterone):** This is a synthetic **progestin** used in oral contraceptive pills (OCPs) and injectable contraceptives. It works primarily by thickening cervical mucus and inhibiting ovulation, not by direct spermicidal action. * **DMPA (Depot Medroxyprogesterone Acetate):** Known commercially as *Antara* (in the government program), this is an **injectable progestogen** administered every 3 months. It acts by suppressing gonadotropins to inhibit ovulation. * **NET-EN (Norethisterone Enanthate):** Known as *Chhaya* (though Chhaya is technically Centchroman; NET-EN is often referred to in the context of the *Antara* program's injectable options), it is an **injectable contraceptive** given every 2 months. Like DMPA, it is hormonal and not a spermicide. **3. NEET-PG High-Yield Pearls:** * **Failure Rate:** Spermicides used alone have a high failure rate (Typical use: ~28%). They are best used in combination with barrier methods (e.g., Diaphragm). * **STI Risk:** Nonoxynol-9 does **not** protect against HIV/STIs. In fact, frequent use can cause vaginal/cervical irritation and epithelial disruption, potentially *increasing* the risk of HIV transmission. * **Vaginal Sponge (Today):** Contains 1000mg of Nonoxynol-9; it provides protection for 24 hours and must be left in place for 6 hours after intercourse.

Question 90: Which is the emergency contraceptive of choice?

A. Oral contraceptive pills (OCP)
B. Danazol
C. Levonorgestrel (Correct Answer)
D. Mifepristone

Explanation: **Explanation:** **Levonorgestrel (LNG)** is the current gold standard and emergency contraceptive of choice due to its high efficacy, safety profile, and wide availability. The standard regimen is a single dose of **1.5 mg** (or two doses of 0.75 mg taken 12 hours apart) administered as soon as possible, ideally within **72 hours** of unprotected intercourse. Its primary mechanism of action is the **inhibition or delay of ovulation** by suppressing the LH surge; it is not an abortifacient. **Analysis of Incorrect Options:** * **Oral Contraceptive Pills (OCP):** Used in the **Yuzpe Regimen** (combined estrogen and progesterone). It is less effective and associated with significant side effects like nausea and vomiting compared to LNG. * **Danazol:** Historically used for emergency contraception but is now obsolete due to poor efficacy and a high side-effect profile. * **Mifepristone:** While highly effective as an emergency contraceptive (even at low doses of 10 mg), it is not the "choice" in many national guidelines (including India’s) due to restricted availability and its primary association with medical abortion. **High-Yield Clinical Pearls for NEET-PG:** * **Most Effective EC:** The **Copper-T 380A** intrauterine device is the most effective method of emergency contraception (failure rate <0.1%) if inserted within 5 days. * **Ulipristal Acetate:** A selective progesterone receptor modulator (30 mg) that is more effective than LNG between 72–120 hours. * **Failure Rate:** LNG has a failure rate of approximately 1–3%. * **Note:** Emergency contraception does not protect against STIs and does not provide ongoing contraceptive protection for subsequent acts of intercourse.

Practice by Chapter

Natural Family Planning Methods

Practice Questions

Barrier Methods

Practice Questions

Hormonal Contraceptives

Practice Questions

Intrauterine Devices

Practice Questions

Emergency Contraception

Practice Questions

Permanent Contraception Methods

Practice Questions

Contraception in Special Populations

Practice Questions

Contraceptive Counseling

Practice Questions

Side Effects and Complications of Contraceptives

Practice Questions

Future Contraceptive Technologies

Practice Questions

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